Hello Dr. ELIAS DARIDO,
Since 2006 my daughter (at that time her weight was about 55 kg) had gastroparesis (vomiting, epigastric pain, weight loss) and GERD grade II. Since that time, she received medical treatments in the form of proton pump inhibitor, prokinetics, antacids but she noticed no significant improvement in her conditions. On April 2011, her condition was worse (45 kg), in the form of severe weight loss, excessive vomiting except for supplements. The CT enterography revealed SMAS with gastric outlet obstruction. On June 2011, she was subjected to laparotomy and a Duodeno-jejunostomy was done between the first part of the Duodenum and loop of jejunum. In her early post-operative period, she suffers from severe abdominal pain (peri-umbilical) post-prandial and still recurrent attacks of vomiting of all kind of foods. So. another CT abdomen with oral and IV contrast was done that revealed stenosis of the Duodeno-jejunostomy versus gastroparesis, gall bladder stones and mild ascites. The endoscopy revealed kink in the outlet of the efferent loop of the Duodeno-jejunostomy. So, another laparotomy was done to her on August 2011, by a midline incision, removal of the old scar, cholecystectomy, formal abdominal exploration of Duodeno-jejunostomy, entero-entrostomy between afferent and the efferent loop of the Duodeno-jejunostomy, a loop Gastro-jeunostomy with entero-enterostomy between the afferent and the efferent loops. All anastomosese were done using staplers (Blue reloads), 2 drains were inserted and she passed a smooth post-operative course with no complications. Partial improvement happened till December 2011, she re-complained of recurrent vomiting to low fatty meals, food containing proteins, meats and chicken, bread, all kind of oils and butter. Another gastric emptying study revealed delayed gastric emptying of solid meal (the same as previous one). An upper GI endoscopy was done on January 2012 that revealed chronic erosive gastritis, GRED grade II, Biliary reflux, Patent Duodeno-jejunostomy and gastro-jejunostomy. Biopsies revealed chronic gastritis with no H. pylori. no malignancy nor specific inflammations. Since that time, she is on medical treatment in the form of Proton pump inhibitor, prokinetics, Erthromycin, nutritional supplements and she followed medically and laboratory to correct any electrolytes disturbance or any hypo-albumineamia. On November 2014, she complained of bloody discharge from her mouth that discovered accidentally when she wakes up every day. Her lab profile was normal with no anemia. Her upper GI revealed chronic erosive gastritis, GRED grade II, Biliary reflux, Patent Duodeno-jejunostomy and gastro-jejunostomy. Biopsies revealed chronic gastritis with no H. pylori. no malignancy nor atypia. Since that time, she is on medical treatment in the form of Proton pump inhibitor, prokinetics, Erthromycin, nutritional supplements and she followed medically and laboratory to correct any electrolytes disturbance or any hypo-albumineamia. On June 2015, at Schon klinik, Nurnberg Furth, Germany, they reversed all the anastomosis except that at SMAS position and implanted Enterra II (40 Kg). After 2 adjustments, there was partial improvement by trying several times to eat low fat sea foods with cooked vegetables (in the beginning always she vomited but after walking about 30 min it could be pass), no carbohydrates except very small amount of dry bread, no oil or butter, no meat, no chicken etc. She always has severe pain at her upper part and/or lower part of her stomach, so she takes 3-4 times per day medication and sometimes injection to calm down the pain. Last month till now, she has again Biliary reflux (during sleeping and sometimes during her sitting down with us) and she lost weight (now her weight 36 kg). Her gastrographin meal (11 January 2017) showed delayed gastric emptying after 30 min. Her Upper GI report indicated GRED type II, Duodeno-jejunostomy, entero-enteric anastmosis, insertion of gastric pace maker, Biliary reflux, hugely dilated stomach and duodenum with competent pylorus, patent gastric outlet, chronic gastritis, no alceration, no masses.
Please Dr., after this long story of failed surgeries and continues pain till now, is your new procedure helpful for my daughter’s complicated case ????
Thank you very much for your attention and for the time you have dedicated to read this letter.
Gastroparesis is probably the most under-appreciated and most misunderstood disorders in medicine. It is a functional rather an anatomic problem. It is a motility disorder as opposed to a mechanical obstruction. Consequently, gastroparesis does not respond to a drainage procedure. A pyloroplasty or gastro-jejunostomy are not suitable solutions. Gastric resection and gastric bypass don’t work either because they do address the underlying problem which is decreased intestinal motility.
The gastric pacemaker makes perfect sense from a theoretical point view. The problem with gastric pacing is that we don’t understand at what frequency and amplitude pacing should be conducted. Furthermore, we don’t understand the underlying myoelectric pathophysiology of gastroparesis to effectively address it with pacing. Randomized, prospective controlled trials have shown no benefits of electric gastric pacing for treatment of gastroparesis.
In the face of such uncertainty and poor outcomes with currently available treatments for gastroparesis out of the box thinking and new studies are needed to come up with effective solutions for gastroparesis. Few years ago, several studies were published showing increased gastric emptying following sleeve gastrectomy. I took this concept and I have applied on several gastroparesis patients. I performed a longitudinal gastrectomy that preserved the gastric antrum and some of the gastric fundus. Patients did very well and experienced complete symptom resolution. I believe that this approach is worth studying and may be the most effective treatment for most gastroparesis patients.
Reference:
Surg Obes Relat Dis. 2012 Nov-Dec;8(6):811-3.
Laparoscopic longitudinal gastrectomy and duodenojejunostomy for treatment of diabetic gastroparesis.
Darido E, Farrell TM.